How Tech & Service Transform the Credentialing Process

The Challenge: Building the Optimal Credentialing Function for a New Health Plan

Dana Guidera was tasked with implementing a credentialing process that would allow Provider Partners Health Plan (PPHP), a new Medicare Advantage plan designed for beneficiaries residing in long-term care facilities, to create their network. With 20 years of credentialing experience in both direct and delegated credentialing arrangements, Dana knew what challenges she wanted to head off for the credentialing team.

And she knew what she needed from a CVO. She was looking for a trusted partner. “When you’re giving up control of the primary source verification,” Dana explained, “you need to have confidence that the files coming back are delivered in a manner that’s easily digestible by your organization.”

The Before: A Black Box, Messy Files, and Lack of Confidence

Before building her PPHP team, Dana was working with a traditional CVO. They would send a file to the CVO, hear nothing back for weeks or months. Her team would then receive a messy file in return that they’d need to dig through to understand, parse and prepare for the credentialing committee.

“We didn’t have a good partnership to begin with,” Dana said. “There was no ease of use with their platform and there wasn’t a lot of confidence: We had to ask a lot of questions on the data returned to us. We didn’t have a partnership where someone is walking us through the process. We needed a firm that is cost-effective, but also delivers on what we receive back.”

The After: A Trusted Partnership

“CredSimple offers a true partnership. All our needs are met. When we request or send a provider file, we receive back data that is easy to understand and user friendly. Also, the turnaround time far exceeded expectations from what I’ve seen of other CVOs.”

“It’s critical that CredSimple is so user friendly,” Dana explained. “It’s easy to train people. That was one of the struggles with our previous CVO — it was so frustrating to use. But now we can just eyeball a provider and understand what’s going on. If a file isn’t clean, the CredSimple platform flags it for us. No more digging.”

Now, Dana plans to hire 1 or 2 credentialing staff per region instead of the 3 or 4 she would have otherwise needed to hire to manually parse all the data.

“CredSimple has taken the frustration out of the credentialing process. The reports are easy to read, export and take right to the credentialing committee. For example, if any providers have open suits from the last five years, it will be flagged right in the system.” CredSimple offers built-in reports that group providers by expired licenses, DEA alerts or malpractice limits — reducing committee prep to minutes.

By partnering with CredSimple, Dana’s team can focus on parts of the credentialing process that need a human touch instead of focusing on repetitive manual work.

The Result: What a Difference a Trusted Partner Makes

“If I have any questions, I can just call Jordan, my service rep.” Dana noted. “He’s been so responsive. It’s like a breath of fresh air. He can help prepare customized reports. That’s a true partnership. You don’t get that with other CVOs.”

“Beyond making sure that we are in compliance, meeting our standards and keeping members out of your harm’s way, the most rewarding part of my job is building a process and see data flow through it. With CredSimple that process was easy to implement.”